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The Quadruple Aim
Quadruple Aim

A Conceptual Framework

Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

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Overview

Through the data validation process, valuable information is gained that can then be used to improve performance around patient care or quality of care metrics.  Improving quality performance may take the form of improving data collection processes, better identifying patients who need additional interventions, or decreasing missed opportunities to provide patients appropriate interventions, among other possibilities. This section includes guidance on leveraging Health IT to improve quality performance including change packages for recommended approaches related to various quality of care measures.

Improving Performance Resources
Clinical Data Elements for UDS eCQMs and their Lookback Timeframes
Clinical Data Elements for UDS eCQMs and their Lookback Timeframes

Clinical Data Elements for UDS eCQMs and their Lookback Timeframes

Each electronic clinical quality measure (eCQM) is composed of data elements in the EHR or health IT system that are evaluated according to the measure specifications.
It is important to identify what data elements need to be transitioned to any new EHR for clinical quality measure continuity and accuracy. This resource identifies clinical data elements in eCQMs that should be considered when transitioning EHRs. These data elements are used in reporting or calculating eCQMs, so their availability or lack thereof in any new EHR system will impact reporting accuracy.

Performance Measure Data Definition Worksheet
Performance Measure Data Definition Worksheet

Performance Measure Data Definition Worksheet

The Performance Measure Data Definition Worksheet can be used during the Quality Improvement (QI) process to assess the alignment of your health center’s workflows and documentation and your EHR vendor’s reporting logic processes.
The Office of the National Coordinator for Health Information Technology (ONC) EHR Certification criteria requires EHR vendors to use eCQM (electronic Clinical Quality Measure) specifications to define measures. Therefore, reported data for a measure should be consistent regardless of EHR vendor. In practice, however, it is important to confirm that your EHR vendor’s reporting logic is consistent with your health center’s definition and workflows, and vice versa, as outlined in this worksheet.

Diabetes Health Center Data Validation Tool
Diabetes Health Center Data Validation Tool

Diabetes Health Center Data Validation Tool

Excel-based Data Validation Tool for health centers to validate their 2021 UDS clinical quality measure reporting of Diabetes Control (HbA1C > 9%) measure on Table 7. Video and written instructions are provided. 

Health Center Data Validation Tool
Health Center Data Validation Tool

Health Center Data Validation Tool

Excel-based Data Validation Tool for health centers to validate their 2021 UDS clinical quality measure reporting of that Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents measure. Video and written instructions are provided. 

Promising Practices in Virtual Integrated Behavioral Health Care
Promising Practices in Virtual Integrated Behavioral Health Care

Promising Practices in Virtual Integrated Behavioral Health Care

With the rapid shift to telehealth services propelled by the COVID-19 pandemic, many community health centers had to rapidly transition to a mechanism of care delivery previously unknown and unfamiliar. Within a matter of days and weeks, health centers creatively found ways to transform workflows and approaches to care delivery to continue to provide care even if the patient was physically distant. This resource highlights promising practices in virtual integrated behavioral health care identified from community health centers. 

Social Determinants of Health (SDoH) Toolkit
Social Determinants of Health (SDoH) Toolkit

Social Determinants of Health (SDoH) Toolkit

This toolkit from Iowa is organized around the three stages of SDOH: Prepare, Test and Spread. The key concepts are organized under each of the stages. This toolkit provides existing and
new tools for each of the 21 concepts with guidance related to when an organization may want to use each tool or concept.

Remote Scribes, Transcription, Talk-to-Type, and Virtual Assistants
Remote Scribes, Transcription, Talk-to-Type, and Virtual Assistants

Remote Scribes, Transcription, Talk-to-Type, and Virtual Assistants

As administrative responsibilities increase, clinical documentation is often the first task to end up suffering. The EHR has created additional administrative burdens on providers such as the need to perform data entry while trying to engage with the patient during the health care visit. Providers have become frustrated and distracted with the documentation requirements, which further hinder connection and communication with the patient. The American Medical Association (AMA) and other groups note that physician burnout is a systemic problem requiring examination and improvements in the system-of-care delivery. Medical record production technologies may be the key to achieving the goal of creating better and timely medical records, while at the same time increasing cost effectiveness. Studies have shown that the utilization of services like medical scribes or voice recognition strengthened the patient and provider experience and is associated with lower rates of burnout. Furthermore, there is evidence that despite the higher overhead costs, additional documentation services can increase clinician productivity, lower billing errors, and foster work-life balance, retention, and wellness.

The obvious demand has driven innovators to provide a solution, and has manifested in scribing tools and resources with distinct modalities, with varying balances between using human capital and technology. This resource assess the strengths and weaknesses of these tools to provide guidance to health centers.

Improving Diabetes Outcomes
Improving Diabetes Outcomes

Improving Diabetes Outcomes

As of CDC's 2017 National Diabetes Statistics Report, 30.3 million people, or 9.4% of the total U.S. population, have diabetes. Of these 30.3 million, only 23.1 million are diagnosed—while the other estimated 7.2 million are undiagnosed. Additionally, more than 1 in 3 adults or 84.1 million people in the U.S. have prediabetes, including nearly half of people age 65 and older. According to 2018 UDS data, an estimated 15.1% of Federally Qualified Health Center patients nationwide have diabetes, an increase over recent years. Of these approx. 2.4 million plus patients living with diabetes, approximately 33% have uncontrolled diabetes, with HbA1c equal to or above 9% or have had no test in the year. This has remained relatively stable since 2016. These statistics bring forth the need for improvement in the care of diabetes; several resources and research outcomes are profiled here with specific takeaways for health centers.

Addressing Childhood Obesity in Health Centers
Addressing Childhood Obesity in Health Centers

Addressing Childhood Obesity in Health Centers

The HITEQ Center interviewed ten health centers and health center partners to identify solutions and promising practices for addressing childhood obesity across the health center program. The focus included how health centers are meeting the Uniform Data System (UDS) measure and how they are taking further steps to identify and intervene with those at risk of obesity leveraging health information technology, electronic health records, and the data they have. Seven key areas are identified in the resulting issue brief.

Community Referral: Using Social Determinants of Health Data & Technology Tools to Connect with Appropriate Community Resources
Community Referral: Using Social Determinants of Health Data & Technology Tools to Connect with Appropriate Community Resources

Community Referral: Using Social Determinants of Health Data & Technology Tools to Connect with Appropriate Community Resources

The collection of data related to patients' non-medical needs through use of Social Determinant of Health (SDoH) assessment tools, can accelerate systemic population health improvement, as well as engage patients in addressing their social non-medical needs (such as transportation, shelter, or intimate partner violence services) through coordinated access to appropriate services or community-based supports. This case study discusses the process a health center may use to identify and stratify need, and profiles a number of community referral platforms, including Aunt Bertha, Now Pow, and 211 Community Information Exchange, for connecting patients to appropriate community resources.

 

HITEQ Highlights: Using Health Information Technology to Facilitate SBIRT Service Delivery in Health Centers
HITEQ Highlights: Using Health Information Technology to Facilitate SBIRT Service Delivery in Health Centers

HITEQ Highlights: Using Health Information Technology to Facilitate SBIRT Service Delivery in Health Centers

This HITEQ Highlights webinar discussed the use of health information technologies (IT) to facilitate the workflow of providing Screening, Brief Intervention, and Referral to Treatment (SBIRT) services. Focus areas included: coding and billing for SBIRT services, using health IT to enhance SBIRT screening, communication, data capture and documentation, clinical decision support, and information sharing and reporting. The webinar presented examples and experiences of health centers currently using health IT to facilitate effective SBIRT service delivery.

EHR Optimization Series: Part Three of Three
EHR Optimization Series: Part Three of Three

EHR Optimization Series: Part Three of Three

The third of a three-part EHR Optimization series focused on establishing goals and expectations for optimizing EHR utilization and sharing proven strategy/tools for optimizing EHR utilization, including slides and related tools. 

EHR Optimization Series: Part Two of Three
EHR Optimization Series: Part Two of Three

EHR Optimization Series: Part Two of Three

The second of a three-part EHR Optimization series focused on establishing goals and expectations for optimizing EHR utilization and sharing proven strategy/tools for optimizing EHR utilization, including slides and related tools.

EHR Optimization Series: Part One of Three
EHR Optimization Series: Part One of Three

EHR Optimization Series: Part One of Three

The first of a three-part EHR Optimization series focused on establishing goals and expectations for optimizing EHR utilization and sharing proven strategy/tools for optimizing EHR utilization, including slides and related tools. 

Quality Report Inventory
Quality Report Inventory

Quality Report Inventory

This Report Inventory tool is a means to make public all available reports, the schedule for publishing to the organization, and their distribution. 

Data Dictionary Tool and Template
Data Dictionary Tool and Template

Data Dictionary Tool and Template

This Data Dictionary provides a single point of reference for data mapping and interpretation for all of the indicators in your quality reports. Organization of the data definitions in this tool provides a reference for the team of all such definitions that impact reports and alerts in the analytics application.

Empanelment: Defining and Establishing Patient-Provider Relationships
Empanelment: Defining and Establishing Patient-Provider Relationships

Empanelment: Defining and Establishing Patient-Provider Relationships

Empanelment is the basis for population health management and the key to continuity of care. Accepting responsibility for a finite number of patients, instead of the universe of patients seeking care in the practice, allows the provider and care team to focus more directly on the needs of each patient. Inside, find guidance for establishing and maintaining patient panels.

How to get your EHR to Match Reality for UDS Measures on Depression
How to get your EHR to Match Reality for UDS Measures on Depression

How to get your EHR to Match Reality for UDS Measures on Depression

Does your agency’s UDS report accurately reflect the work you do for depression screening and other behavioral health integration activities? Join this webinar to learn strategies and steps your team can use to make the most of the EHR to support improved health outcomes for your patients. Gain insight from a health technology expert and practical tips from an agency who learned to make their EHR a true part of the team to improve UDS depression measures through inputting and analyzing depression screening data from the EHR.

Using Health Technology to Improve Performance on Clinical Quality Measures
Using Health Technology to Improve Performance on Clinical Quality Measures

Using Health Technology to Improve Performance on Clinical Quality Measures

HealthNet’s successful use of Health IT to move metrics is highlighted in case studies focused on the value of leveraging IT to standardize care and improve patient outcomes. With the assistance of electronic health records and a variety of IT interventions, HealthNet has reduced low birth weights, improved care outcomes for pediatric patients, and significantly increased patient satisfaction.

Acknowledgements

This resource collection was compiled by the HITEQ Center staff with guidance from HITEQ Advisory Committee members and collaborators of the HITEQ Center.